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Management of Cleft Palate in Puppies Using A Temporary Prosthesis: A Report of Three Cases - MDPI
veterinary
           sciences
Case Report
Management of Cleft Palate in Puppies Using A
Temporary Prosthesis: A Report of Three Cases
Theresa Conze 1, *, Isabelle Ritz 2 , Rainer Hospes 1 and Axel Wehrend 1
 1    Clinic for Obstetrics, Gynecology and Andrology of Large and Small Animals with Ambulatory Service,
      Faculty of Veterinary Medicine, Justus-Liebig-University, 35392 Giessen, Germany;
      rainer.hospes@vetmed.uni-giessen.de (R.H.); axel.wehrend@vetmed.uni-giessen.de (A.W.)
 2    Department of Veterinary Clinical Science, Small Animal Clinic, Surgery, Justus-Liebig-University,
      35392 Giessen, Germany; mail@isabelle.ritz.de
 *    Correspondence: theresa.conze@vetmed.uni-giessen.de; Tel.: +49-641-9938-707
                                                                                                   
 Received: 26 May 2018; Accepted: 20 June 2018; Published: 24 June 2018                            

 Abstract: Cleft palate in dogs is a congenital defect that mostly leads to euthanasia of the affected
 puppy. If an attempt is made to raise the puppy, it is generally fed via an orogastric tube. Here,
 we describe the management of cleft palate in three puppies (two Boxers, one Collie) using a
 customised temporary prosthesis, which allowed the puppies to be bottle-fed and successfully
 raised by their owners (Cases 2 and 3) and the author (Case 1). The temporary palatal prosthesis was
 manufactured from a mouthguard intended for human children, which is made of thermoplastic
 silicone. The preparation procedure was simple and cost-effective. All puppies underwent corrective
 surgery at 5–6 months of age. After surgery, one of the Boxer puppies showed mandibular
 mesioclusion, while the other two showed no aberrations. All puppies gained the same amount of
 weight as their littermates, although the weight gain of the two Boxers was slower than that of their
 littermates. In summary, this case report describes an easy and effective way to raise puppies with
 cleft palate until corrective surgery can be performed.

 Keywords: cleft palate; palatoschisis; puppy; temporary prosthesis

1. Introduction
     Palatoschisis, also known as cleft palate (CP), is a craniofacial defect characterised by an abnormal
communication between the oral and nasal cavities and is one of the most common craniofacial
defects in dogs [1–3]. Because of this abnormal connection, suckling is impaired and the risk of
aspiration pneumonia is high [4]. The only successful treatment for CP is corrective surgery, which is
best performed once maxillofacial growth has slowed down or ceased completely [5]; Fiani et al. [5]
recommend an age of about 4–6 months [5]. If corrective surgery is performed earlier than the
recommended age, there is a high risk of dehiscence and maxillary growth delay [5]. However,
raising puppies until the appropriate age for corrective surgery is challenging, and most puppies are
euthanised because of the costs and intensive care required. Neonates that are raised until an age
appropriate for surgery are mostly fed by an orogastric tube [6].
     In the present report, we describe the successful management of CP using a customised temporary
prosthesis in three puppies, and demonstrate an easy and affordable way to raise puppies with CP
until corrective surgery can be performed.

Vet. Sci. 2018, 5, 61; doi:10.3390/vetsci5030061                                www.mdpi.com/journal/vetsci
Management of Cleft Palate in Puppies Using A Temporary Prosthesis: A Report of Three Cases - MDPI
Vet. Sci.
Vet. Sci. 2018,
          2018, 5,
                5, 61
                   61                                                                                                            22 of
                                                                                                                                    of 77

2. Case Presentation
2. Case Presentation
2.1. Cases
2.1. Cases
      Case 1 involved a 3-day-old male Boxer puppy that presented at the Clinic for Obstetrics,
      Case 1 involved
Gynecology                    a 3-day-old
                  and Andrology       of Large   male  andBoxer
                                                             Smallpuppy
                                                                      Animalsthatwith
                                                                                    presented     at the Service
                                                                                          Ambulatory        Clinic for    Obstetrics,
                                                                                                                      of the   Justus-
Gynecology       and  Andrology      of  Large    and     Small   Animals    with   Ambulatory
Liebig University in Germany. The owner reported that the puppy was very active and continuously    Service   of  the  Justus-Liebig
UniversityNonetheless,
suckling.      in Germany. he  Thedid
                                    ownernot reported
                                                gain weight, that the
                                                                   andpuppy     was very
                                                                         the owner          active and
                                                                                       frequently          continuously
                                                                                                     observed                suckling.
                                                                                                                   nasal discharge
Nonetheless,
after  suckling.he did not gain weight, and the owner frequently observed nasal discharge after suckling.
      On     examination,thethe
      On examination,                 puppy
                                   puppy            exhibited
                                              exhibited      a good a good
                                                                       general general
                                                                                  conditioncondition
                                                                                               and wasand   verywas      very
                                                                                                                   lively.       lively.
                                                                                                                            Intraoral
Intraoral examination
examination       revealed CP  revealed
                                  (FigureCP        (Figure
                                              1). The          1). characterised
                                                          CP was     The CP was characterised
                                                                                      by a midline defectby a midline
                                                                                                                in the hard defect   in
                                                                                                                                palate
the  hard    palate  and   a caudally     divergent        defect   in the  soft  palate.
and a caudally divergent defect in the soft palate. The defect was moderately wide, and no The   defect   was   moderately        wide,
and no asymmetrical
asymmetrical                facial growth
                   facial growth     could be   could     be detected.
                                                    detected.     CP was  CPclassified
                                                                               was classified
                                                                                          as “- -asH“-S- HH -S-“
                                                                                                               H according
                                                                                                                   - -“ according     to
                                                                                                                                 to the
the LAHSAL
LAHSAL             classification
              classification   [7]. [7].
                                    No No other other     congenital
                                                    congenital          diseases
                                                                    diseases   were were   detected,
                                                                                       detected,   andand the the
                                                                                                               puppypuppy     showed
                                                                                                                         showed      no
no  signs    of pneumonia.        When      milk    replacer     (Babydog      Milk  ® , Royal Canin, Köln, Germany) was
signs of pneumonia. When milk replacer (Babydog Milk® , Royal Canin, Köln, Germany) was offered,
offered,
the  puppy the suckled
                puppy suckled      immediately.
                          immediately.        Although   Although     he showed
                                                              he showed      nasal nasal   discharge
                                                                                     discharge    and and     occasional
                                                                                                        occasional          sneezing,
                                                                                                                       sneezing,     he
he demonstrated        a good    appetite.     He    required     a long  time   to consume     the
demonstrated a good appetite. He required a long time to consume the amount of milk necessary for    amount      of  milk  necessary
for gaining
gaining    body body   weight.
                   weight.        Because
                             Because    of his of good
                                                  his good      general
                                                           general        condition,
                                                                     condition,          an attempt
                                                                                   an attempt         at raising
                                                                                                 at raising   him himwas was
                                                                                                                           made  made
                                                                                                                                   and
and  the   puppy     was  assigned
the puppy was assigned to the clinic. to   the   clinic.
      Case 22 involved
      Case       involvedaafemale
                                femaleBoxer
                                          Boxerthat  thatpresented
                                                            presented  with  a congenital
                                                                          with   a congenitalpalatal  defect
                                                                                                  palatal      on the
                                                                                                             defect   onday
                                                                                                                          theof   birth.
                                                                                                                                day  of
The  puppy      was   diagnosed     with     cleft  lip   and  palate   (CLP),    or cheilognathopalatoschisis,
birth. The puppy was diagnosed with cleft lip and palate (CLP), or cheilognathopalatoschisis, which                       which    was
classified
was          as “- -asH“-
      classified        SH -H A L”
                                 S Haccording
                                       A L” according to the LAHSAL        classification,
                                                                 to the LAHSAL               which is awhich
                                                                                       classification,      systemisfor   classifying
                                                                                                                       a system     for
clefts  [7]. The   defect  was   narrow     in  both    the hard    and  soft palate,   measuring
classifying clefts [7]. The defect was narrow in both the hard and soft palate, measuring between    between     1–2   mm    in width.
                                                                                                                                    1–2
No facial
mm           growth
      in width.     Noabnormalities
                         facial growthwere         observed. The
                                              abnormalities        were puppy    showed
                                                                          observed.     Thea normal      birth weight,
                                                                                              puppy showed                 was lively,
                                                                                                                    a normal      birth
and  showed       no other   deformities      during      examination.
weight, was lively, and showed no other deformities during examination.
      Case 33involved
      Case        involved a male   Collie
                               a male          that presented
                                           Collie                   with mild
                                                       that presented       with bronchopneumonia,
                                                                                    mild bronchopneumonia,  which waswhichdiagnosedwas
based on a based
diagnosed      clinicalonexamination,       a complete ablood
                           a clinical examination,                    count,blood
                                                                complete      and an    ultrasound
                                                                                     count,  and an of     the lungs.ofThis
                                                                                                       ultrasound          the puppy
                                                                                                                                lungs.
presented
This puppyatpresented
                  the age ofat12the days.
                                      age The of 12puppy        was puppy
                                                        days. The     found to was have
                                                                                     founda continuous       hard and soft
                                                                                              to have a continuous          hardpalate
                                                                                                                                   and
defect,   classified  as  “- - H  S H   - -“  according       to the  LAHSAL       classification   [7].
soft palate defect, classified as “- - H S H - -“ according to the LAHSAL classification [7]. The defect  The  defect   was    narrow,
and narrow,
was   no facialand growth    abnormalities
                       no facial                  were seen. The
                                   growth abnormalities             wereowners    of both
                                                                          seen. The         puppies
                                                                                       owners    of bothwere   willing
                                                                                                            puppies       to attempt
                                                                                                                       were    willing
raising   them.
to attempt raising them.

                        Figure 1. Cleft palate in a 3-day-old purebred male Boxer puppy (Case 1).
                        Figure 1. Cleft palate in a 3-day-old purebred male Boxer puppy (Case 1).

2.2. Customisation of A Palatal Prosthesis
      A temporary prosthesis was crafted from a mouthguard intended for human children (Wilson
Single Density Youth Mouthguard; Wilson, Chicago, IL, USA), which is made of thermoplastic
silicone and can be reformed by heating in hot water. About 1–2 cm of the mouthguard was cut off
Management of Cleft Palate in Puppies Using A Temporary Prosthesis: A Report of Three Cases - MDPI
Vet. Sci. 2018, 5, 61                                                                                                            3 of 7

2.2. Customisation of A Palatal Prosthesis
       A 2018,
 Vet. Sci.  temporary
                5, 61       prosthesis was crafted from a mouthguard intended for human children                                 3 of 7
(Wilson Single Density Youth Mouthguard; Wilson, Chicago, IL, USA), which is made of thermoplastic
 (Figure 2a)
silicone     andand
                  canplaced     in a cup
                        be reformed      bywith   boiling
                                             heating        water.
                                                       in hot        After
                                                                 water.      a few1–2
                                                                          About      seconds,
                                                                                         cm of the material
                                                                                                      mouthguardsoftened
                                                                                                                       wasand      the
                                                                                                                             cut off
 silicone2a)
(Figure      could
                and beplaced
                        reformed in afor
                                       cupabout
                                             with30–60   seconds.
                                                   boiling    water.Thus,
                                                                        Aftera plate
                                                                               a fewwith     a height
                                                                                       seconds,     theof  approximately
                                                                                                        material    softened  0.3and
                                                                                                                                   cm
 wassilicone
the     prepared.
                could  During     the crafting
                         be reformed              procedure,
                                           for about              the mouthguard
                                                      30–60 seconds.        Thus, a plate was   heated
                                                                                              with        andofsoftened
                                                                                                     a height                several
                                                                                                                  approximately
 times.
0.3  cm wasAfterprepared.
                  hardening,      the edges
                              During           of the plate
                                        the crafting           were cut
                                                       procedure,      the off until a sizewas
                                                                           mouthguard         matching
                                                                                                  heated that
                                                                                                            and of  the upper
                                                                                                                 softened         jaw
                                                                                                                            several
 of the After
times.     puppy    was obtained
                 hardening,             (Figure
                                  the edges       2b).plate
                                              of the   When      the cut
                                                              were    optimal    sizea and
                                                                          off until     size thickness
                                                                                              matching that(approximately
                                                                                                                of the upper4jaw   cm
 long,
of  the 2puppy
            cm wide,
                   was 0.3   cm thick)
                         obtained          were
                                     (Figure     achieved,
                                               2b). When the   theoptimal
                                                                    siliconesize
                                                                               plate
                                                                                  andwas    pressed(approximately
                                                                                        thickness      against the upper4 cmjawlong,of
2the
   cmpuppy
        wide, 0.3(Figure     2c) towere
                      cm thick)       produce    a prosthesis
                                           achieved,   the siliconethatplate
                                                                          was was
                                                                                adjusted
                                                                                      pressedto against
                                                                                                 the maxilla     (Figure
                                                                                                           the upper    jaw2d).    No
                                                                                                                              of the
 anaesthesia
puppy      (Figurewas2c) required
                          to produce  during    this procedure.
                                         a prosthesis                 The prosthesis
                                                        that was adjusted                  was only
                                                                                to the maxilla          inserted
                                                                                                   (Figure   2d). Noinanaesthesia
                                                                                                                       the mouth
 during
was         bottle during
       required      feedingthisandprocedure.
                                      did not require       fixation. The
                                                    The prosthesis       was puppies      tolerated
                                                                               only inserted           themouth
                                                                                                  in the     prosthesis
                                                                                                                    duringwell    and
                                                                                                                              bottle
 showed and
feeding      rapiddidandnotnormal
                              requiremilk   intake.The
                                        fixation.    Although
                                                          puppies  small   amounts
                                                                      tolerated    theofprosthesis
                                                                                          nasal discharge
                                                                                                       well andwere   occasionally
                                                                                                                   showed     rapid
 observed
and    normal  after
                  milk drinking,
                          intake. sneezing
                                    Althoughand       coughing
                                                  small   amounts   were    neverdischarge
                                                                        of nasal    observed,were  and there    were noobserved
                                                                                                        occasionally       signs of
 aspiration.
after   drinking,After   2 weeks,
                      sneezing     anda coughing
                                         new prosthesis       had toobserved,
                                                     were never         be customised,
                                                                                    and thereas described
                                                                                                  were no signsabove,  because of
                                                                                                                    of aspiration.
 physiological
After   2 weeks, growth         of the puppy.
                     a new prosthesis        had toAtbe6 customised,
                                                          weeks of age,    as the  ownersabove,
                                                                              described       beganbecause
                                                                                                       mixing of thephysiological
                                                                                                                      puppy milk
 (Babydog
growth         Milk®
            of the      , Royal
                    puppy.     At Canin,
                                   6 weeksKöln,     Germany)
                                              of age,  the owners withbegan
                                                                          wet dog
                                                                                mixingfoodthe(Starter
                                                                                               puppyMousse®        , Royal Milk
                                                                                                         milk (Babydog       Canin, ®,

 Köln, Germany),
Royal     Canin, Köln,   and   at 2.5 months
                            Germany)       withofwetage,
                                                       dogthey  changed
                                                              food          theMousse
                                                                     (Starter             ®
                                                                                 feed to commercial
                                                                                            , Royal Canin, dry Köln,
                                                                                                                dog food    (Puppy
                                                                                                                       Germany),
 Large
and        Breed®
       at 2.5  months, Eukanuba,
                           of age, they Coevorden,
                                           changed the  Netherlands),       which the
                                                            feed to commercial         dry puppies
                                                                                            dog foodcould(Puppy eatLarge
                                                                                                                      without
                                                                                                                           Breedthe ®,

 prosthesis.Coevorden,
Eukanuba,       The puppies        showed no difficulty
                                Netherlands),     which theinpuppies
                                                                  drinking     water.
                                                                           could   eat without the prosthesis. The puppies
showed no difficulty in drinking water.

       Figure 2.2. A
      Figure       A small
                      small portion
                              portion ofof the
                                           the Wilson
                                                Wilson Single
                                                         Single Density
                                                                 Density Youth
                                                                             Youth Mouthguard
                                                                                     Mouthguard (Wilson
                                                                                                    (Wilson Single
                                                                                                              Single Density
                                                                                                                      Density
      Youth
       YouthMouthguard,
                Mouthguard, Wilson,
                                  Wilson,Chicago,
                                           Chicago, IL,
                                                      IL,USA)
                                                           USA) isis cut
                                                                      cutoff
                                                                          off(a).
                                                                              (a). A
                                                                                   A plate
                                                                                      plate matching
                                                                                            matching the
                                                                                                       the size
                                                                                                           size of
                                                                                                                of the
                                                                                                                    the upper
                                                                                                                        upper
      jaw   is crafted by   repeated   heating,  softening,   and  reforming    the  thermoplastic  silicone
       jaw is crafted by repeated heating, softening, and reforming the thermoplastic silicone (b). The warm  (b). The  warm
      silicone
       silicone plate
                  plate is
                         is pressed
                            pressed against
                                      against the
                                               the upper
                                                   upper jawjawofofthethepuppy
                                                                          puppy(c).(c). The
                                                                                        Thecustomised
                                                                                             customised temporary
                                                                                                          temporary palatal
                                                                                                                       palatal
      prosthesis
       prosthesisprepared
                    preparedfor  forpuppies
                                     puppies with
                                               with cleft
                                                     cleft palate
                                                           palate from
                                                                   from the
                                                                          the Wilson
                                                                               Wilson Single
                                                                                         Single Density
                                                                                                Density Youth
                                                                                                        Youth Mouthguard
                                                                                                                Mouthguard
      for
       for human
           human children
                     children(d).
                                (d).

2.3. Further Therapies
     All puppies were treated with frequent inhalation of ambroxol during the first 2 weeks
(Mucosolvan® , 6 mg per inhalation, Boehringer Ingelheim, Ingelheim am Rhein) to clear the upper
respiratory tract. The puppy in Case 3 received amoxicillin–clavulanic acid for 10 days (Synulox® ,
12.5 mg/kg body weight, orally, twice a day, Zoetis, Berlin, Germany) for the management of
bronchopneumonia.
Management of Cleft Palate in Puppies Using A Temporary Prosthesis: A Report of Three Cases - MDPI
Vet. Sci. 2018, 5, 61                                                                                                   4 of 7

2.3. Further Therapies
       All puppies were treated with frequent inhalation of ambroxol during the first 2 weeks
(Mucosolvan® , 6 mg per inhalation, Boehringer Ingelheim, Ingelheim am Rhein) to clear the
upper respiratory tract. The puppy in Case 3 received amoxicillin–clavulanic acid for 10 days
 Vet. Sci. 2018, 5, 61                                                                           4 of 7
(Synulox® , 12.5 mg/kg body weight, orally, twice a day, Zoetis, Berlin, Germany) for the management
of bronchopneumonia.
 2.4. Development
2.4. Development
      The puppy in Case 1 was raised by one of the authors in isolation from its littermates, while the
otherThe
       twopuppy
           puppies in were
                      Case raised
                            1 was along
                                    raisedwith
                                            by onetheir
                                                     oflittermates
                                                        the authorsbyintheir respective
                                                                         isolation from owners.      Both ofwhile
                                                                                          its littermates,     them
the other two puppies were raised along with their littermates by their respective owners. BothAll
suckled  from  their  mothers   without   the  prosthesis;  however,   there was  no  effective   milk  intake.   of
puppies   were   fed  by  bottle  with  the  prosthesis   in place.  The  puppy   in  Case   2  showed
them suckled from their mothers without the prosthesis; however, there was no effective milk intake.       signs  of
pneumonia    at approximately     6  weeks   of age, but  recovered   and  developed   well  after
All puppies were fed by bottle with the prosthesis in place. The puppy in Case 2 showed signs of    the  treatment
with amoxicillin–clavulanic
pneumonia    at approximatelyacid      (Synulox®
                                  6 weeks   of age,, but
                                                     12.5recovered
                                                           mg/kg bodyandweight,
                                                                          developedorally,
                                                                                       welltwice
                                                                                             after athe
                                                                                                      day,   Zoetis,
                                                                                                        treatment
Berlin, Germany).    Although    the puppies   ®showed   good  food  intake, the two  Boxer   puppies
with amoxicillin–clavulanic acid (Synulox , 12.5 mg/kg body weight, orally, twice a day, Zoetis, Berlin,  exhibited
slower body
Germany).     weight gain
            Although         than their
                        the puppies       littermates,
                                      showed            while
                                                 good food      the Collie
                                                             intake, the twodeveloped   at the exhibited
                                                                              Boxer puppies      same rateslower
                                                                                                              as his
littermates.
body  weight gain than their littermates, while the Collie developed at the same rate as his littermates.

2.5. Outcomes
2.5. Outcomes and
              and Follow-up
                  Follow-up
      Between 5–6
     Between     5–6 months
                      months ofofage,age,allall
                                              three
                                                 threepuppies
                                                          puppies(Figure   3) underwent
                                                                     (Figure    3) underwent  corrective  surgery.
                                                                                                   corrective         Pre-
                                                                                                                 surgery.
operatively,  a  complete     blood  count    and   a blood    chemistry    test  were  performed
Pre-operatively, a complete blood count and a blood chemistry test were performed on all dogs.         on  all  dogs.  All
values
All      were
    values     within
            were   withinnormal
                           normal range.
                                     range.ForForcorrective
                                                   correctivesurgery,
                                                                surgery,thethe medially                     double-flap
                                                                                medially repositioned double-flap
technique (von
technique   (von Langenbeck
                    Langenbeck technique) was used for the           the hard
                                                                           hard palate
                                                                                  palate [8][8] and
                                                                                                and the
                                                                                                      the double-layer
                                                                                                           double-layer
appositional technique
appositional   technique was usedused forfor the
                                             the soft
                                                  soft palate.
                                                       palate. The
                                                                The surgical
                                                                      surgical wounds
                                                                                 wounds healed
                                                                                             healed well,
                                                                                                     well, with
                                                                                                           with normal
                                                                                                                  normal
symmetry between
symmetry    between thethe right
                            right and
                                  and left
                                        left sides
                                             sides of
                                                    of the
                                                        the maxilla
                                                            maxilla (Figure
                                                                      (Figure 4).
                                                                                4). The
                                                                                    The puppy
                                                                                         puppy in in Case
                                                                                                     Case 11 developed
                                                                                                              developed
mandibular
mandibular    mesioclusion     after surgery.    The  cleft lip wound     in the  puppy     in
                                     surgery. The cleft lip wound the puppy in Case 2 opened upCase  2 opened    up after
                                                                                                                     after
surgery, but
surgery,  but the
               the owner
                    owner decided
                             decided against
                                       against further
                                                 further corrective
                                                           corrective surgery
                                                                        surgery because
                                                                                   because there
                                                                                              there was
                                                                                                     was no
                                                                                                          no functional
                                                                                                               functional
constraint. All puppies achieved the same body size and weight
constraint.                                                            weight as as their
                                                                                    their littermates.
                                                                                           littermates. At the time
                                                                                                                  time of
                                                                                                                        of
writing  this article, the  dogs  were    aged   2–4  years.   All dogs   were   healthy    and
writing this article, the dogs were aged 2–4 years. All dogs were healthy and showed no problems showed    no   problems
associated with
associated  with their
                   their congenital
                          congenitaldefects
                                       defects(Figure
                                                 (Figure5). 5).The
                                                                Thecleft liplip
                                                                      cleft  persisted
                                                                                 persistedin the  puppy
                                                                                              in the puppyin Case   2, but
                                                                                                               in Case  2,
thisthis
but  represents   a cosmetic
         represents            defect
                      a cosmetic       only.
                                   defect  only.

       Figure  3. Cleft
       Figure 3.  Cleft palate/cleft  lip and
                        palate/cleft lip  and palate
                                              palate on
                                                     on the
                                                        the day
                                                            day of
                                                                of corrective
                                                                   corrective surgery
                                                                              surgery in
                                                                                      in Case
                                                                                         Case 11 (a),
                                                                                                 (a), Case
                                                                                                      Case 22 (b)
                                                                                                              (b) and
                                                                                                                  and
       Case 3 (c).
       Case 3 (c).
Management of Cleft Palate in Puppies Using A Temporary Prosthesis: A Report of Three Cases - MDPI
Vet. Sci. 2018, 5, 61                                                                                                              5 of 7
Vet. Sci. 2018, 5, 61                                                                                                              5 of 7
 Vet. Sci. 2018, 5, 61                                                                                                              5 of 7

       Figure
       Figure
        Figure4.4. Intraoral
                4. Intraoral  images
                    Intraoral images  of
                               images of  Case
                                          Case 222 (a)
                                      of Case      (a)  and
                                                    (a) and Case
                                                            Case 333 (b)
                                                        and Case     (b)
                                                                      (b) 333 days
                                                                              days after
                                                                              days after surgery,
                                                                                   after surgery,   and
                                                                                          surgery,and    Case
                                                                                                         Case111(c)
                                                                                                     andCase     (c)
                                                                                                                 (c)222months
                                                                                                                        months
                                                                                                                        months
       after
       after surgery.
        aftersurgery.    Cases
              surgery.Cases     2 and
                         Cases22and   3  did
                                  and33did   not
                                         didnot    require
                                             notrequire     any
                                                    requireany  further
                                                            anyfurther        surgery.
                                                                 furthersurgery.       Case
                                                                              surgery.Case   1 still
                                                                                       Case11still   showed
                                                                                               stillshowed   some
                                                                                                      showedsome      fistulas
                                                                                                                      fistulas222
                                                                                                              somefistulas
       months
       months    after
        monthsafter     surgery,
                 aftersurgery,    which
                        surgery,which    were
                                  whichwere    successfully
                                         weresuccessfully     closed.
                                               successfullyclosed.
                                                              closed.

          Figure
          Figure5.5.
         Figure      Intraoral
                  5.Intraoral  images
                     Intraoralimages  of
                               imagesof  Case
                                         Case111(a)
                                      ofCase     (a)
                                                 (a)444years
                                                       years and
                                                       years and Case
                                                                 Case 222 (b)
                                                             and Case     (b) and
                                                                              and Case
                                                                                  Case 33 (c)
                                                                                          (c) 22 years
                                                                                                 yearsafter
                                                                                                 years aftersurgery.
                                                                                                       after  surgery.
                                                                                                             surgery.

 3. Discussion
 3. Discussion
3.   Discussion
       Although
       Although CP
       Although      CP
                     CP isis one
                           isone
                              oneofof  the
                                   ofthe   most
                                       themost     common
                                           mostcommon          congenital
                                                   commoncongenital             craniofacial
                                                               congenitalcraniofacial           defects
                                                                                craniofacial defects
                                                                                                 defects inin  dogs,
                                                                                                           indogs,
                                                                                                               dogs,mostmost   puppies
                                                                                                                        mostpuppies
                                                                                                                               puppies
 are  euthanised
 are euthanised
are   euthanised or   or  die
                      ordie    because
                          diebecause
                                becauseof of aspiration
                                          ofaspiration      pneumonia.
                                             aspirationpneumonia.              Corrective
                                                            pneumonia. Corrective             surgery
                                                                               Corrective surgery
                                                                                              surgery cancan
                                                                                                         can be be  performed
                                                                                                                be performed
                                                                                                                    performed at   at an
                                                                                                                                   at an
                                                                                                                                       an
 age  of
 age of
age       about
      of about    4–6
          about 4–6     months
                   4–6 months
                        months [5].[5]. Until
                                   [5]. Until  the
                                         Until the   puppy
                                               the puppy      is old   enough
                                                     puppy is old enough           for  surgery,
                                                                       enough for surgery,          nutrition
                                                                                        surgery, nutrition
                                                                                                    nutrition has has  to
                                                                                                                  has to  be
                                                                                                                       to be  ensured,
                                                                                                                           be ensured,
                                                                                                                              ensured,
 and
 andthe
and    the   risk
        therisk
             risk   of
                    of aspiration
                        aspiration
                 of aspiration         pneumonia
                                        pneumonia
                                  pneumonia      has tohas
                                                       has   to
                                                             to bebe minimised.
                                                         be minimised. minimised.        In
                                                                                         In children,
                                                                              In children,    a feedingaaobturator
                                                                                             children,        feeding
                                                                                                              feeding isobturator
                                                                                                                          obturator
                                                                                                                            commonly    is
                                                                                                                                        is
 commonly
 commonly       provided
                 provided     until
                              until  corrective
                                      corrective   surgery
                                                   surgery    is
                                                              is  performed
                                                                  performed       [9,10].
                                                                                  [9,10].   The
                                                                                            The   preparation
                                                                                                  preparation
provided until corrective surgery is performed [9,10]. The preparation of prosthodontic obturators after           of
                                                                                                                   of  prosthodontic
                                                                                                                       prosthodontic
 obturators
corrective      after
                after corrective
 obturatorssurgery     corrective   surgery
                                     surgery
                         for congenital     as for
                                               wellcongenital
                                               for  congenital
                                                      as acquired  as well
                                                                   as cleft   as
                                                                              as acquired
                                                                      well palates
                                                                                 acquired     cleft palates
                                                                                              cleftand
                                                                                        in dogs      palates   in
                                                                                                               in dogs
                                                                                                        cats has    beenand
                                                                                                                   dogs   and  cats
                                                                                                                                cats has
                                                                                                                                     has
                                                                                                                            previously
 been   previously
 been previously
described     [2,11,12].described
                        described    [2,11,12].
                                      [2,11,12].
                           Martinez-Sanz         Martinez-Sanz
                                                 Martinez-Sanz
                                              et al. [4] described et et  al. [4]  described
                                                                       theal.preparation
                                                                               [4] described     the  preparation
                                                                                                 the preparation
                                                                                             of customised             of
                                                                                                                 feeding   customised
                                                                                                                        of customised
                                                                                                                            teats using
afeeding
 feeding    teats
            teats using
                    using aa thermovacuum-forming
  thermovacuum-forming         thermovacuum-forming
                                    machine under anaesthesia  machine
                                                                machine      under
                                                                              under
                                                                        for the        anaesthesia
                                                                                       anaesthesia
                                                                                  management        andfor  the
                                                                                                             the management
                                                                                                       forraising  management
                                                                                                                    of puppies with and
                                                                                                                                    and
 raising
 raising   of puppies
           of surgery.    with
               puppies Although  CP   before
                          with CP before     surgery.     Although
                                              surgery. Although         they
                                                                        they    described
                                                                                described    an   effective   way   to  raise  puppies
CP   before                             they described     an effective      way    to raise an   effective
                                                                                              puppies     with wayCP,tothe
                                                                                                                        raise  puppies
                                                                                                                            procedure
 with
 with
for     CP,
         CP, the
              the procedure
     manufacturing procedure      for  manufacturing
                                  forand
                          the teats    manufacturing       the
                                                           the teats
                                           palatal prosthesis    teats  and
                                                                         and palatal
                                                                    is complex       and prosthesis
                                                                                palatal   prosthesis    is
                                                                                                        is complex
                                                                                           requires special complex      and
                                                                                                                         and requires
                                                                                                                 equipment     requires
                                                                                                                                as well
 special
 special equipment as well as anaesthesia. In the cases presented here, the preparation procedure for
           equipment       as well   as  anaesthesia.    In the   cases   presented       here, the   preparation       procedure     for
 the
 the palatal
      palatal prosthesis
                prosthesis was was inexpensive,
                                     inexpensive, simple,
                                                      simple, andand effective;
                                                                       effective; moreover,
                                                                                      moreover, no  no anaesthesia
                                                                                                        anaesthesia was  was needed,
                                                                                                                               needed,
 all
 all of
     of which
         which areare important
                       important factors
                                     factors in
                                              in the
                                                  the willingness
                                                       willingness of   of owners
                                                                           owners to   to raise
                                                                                           raise aa puppy
                                                                                                    puppy withwith CP.
                                                                                                                     CP. Although
                                                                                                                           Although aa
Vet. Sci. 2018, 5, 61                                                                                              6 of 7

as anaesthesia. In the cases presented here, the preparation procedure for the palatal prosthesis was
inexpensive, simple, and effective; moreover, no anaesthesia was needed, all of which are important
factors in the willingness of owners to raise a puppy with CP. Although a palatal prosthesis needs to
be prepared several times as the puppy grows, only one mouthguard (Wilson Single Density Youth
Mouthguard) could supply all the material necessary for all the prostheses. Furthermore, the owners
could replicate the manufacturing procedure after observing it once, although regular supervision
by a veterinarian is recommended. This approach allows the puppy to grow up in a normal social
environment. This approach also makes bottle feeding and suckling possible (which are important
for normal craniofacial growth [13]) with minimal risk of milk aspiration and subsequent pneumonia.
This prosthesis allows for the normal raising of such puppies until most of the maxillofacial growth is
complete, preventing maxillofacial deformities and inhibiting maxillary growth that can occur because
of palatoplastics [8,14,15]. Although the puppy in Case 1 developed mandibular mesioclusion after
surgery, this can be attributed to the breed and was not considered a consequence of the surgery.
The optimal time and technique for surgery should be chosen according to the size of the cleft
palate [7,16–19]. Although there are various reasons for the development of congenital palatoschisis,
there is a genetic predisposition [20–22], and castration of the animal is strongly advised.

4. Conclusions
     In summary, we described the successful management of puppies with CP using a temporary
customised prosthesis, which allowed them to be bottle-fed and successfully raised until corrective
surgery could be performed. The findings from this report show that a puppy with CP can be raised
with little effort and at low cost, thus encouraging owners to seek appropriate treatment for such
puppies instead of considering euthanasia.

Author Contributions: T.C. conceived the idea for manufacturing the prosthesis, customised it for the three
puppies, and raised the puppy in Case 1; I.R. performed the corrective surgery for all puppies and contributed
with her broad knowledge of stomatology; and R.H. and A.W. supported and financed the project. All authors
have reviewed the article and approved it for final submission.
Funding: This research received no external funding.
Acknowledgments: We thank Daniela Graulich for the help with all the cleft palate puppies.
Conflicts of Interest: The authors declare no conflicts of interest.

References
1.    Hoskins, J.D. The Respiratory System. In Veterinary Pediatrics. Dogs and Cats from Birth to Six Months, 2nd ed.;
      Hoskins, J.D., Ed.; W.B. Saunders: Philadelphia, PA, USA, 1995; p. 73, ISBN 0721638872.
2.    Lee, J.I.; Kim, Y.S.; Kim, M.J.; Lee, J.; Choi, J.H.; Yeom, D.B.; Park, J.M.; Hong, S.H. Application of a temporary
      palatal prosthesis in a puppy suffering from cleft palate. J. Vet. Sci. 2006, 7, 93–95. [CrossRef] [PubMed]
3.    Hedlund, C.S. Surgery of the oral cavity and oropharynx. In Small Animal Surgery, 2nd ed.; Fossum, T.W.,
      Ed.; Mosby: St. Louis, MO, USA, 2002; pp. 274–306, ISBN 9781560535799.
4.    Martinez-Sanz, E.; Casado-Gomez, I.; Martin, C.; López-Gordillo, Y.; González, P.; Rodríguez-Bobada, C.;
      Paradas, I.; González-Meli, B.; Maldonado, E.; Maestro, C.; et al. A new technique for feeding dogs with a
      congenital cleft palate for surgical research. Lab. Anim. 2011, 45, 70–80. [CrossRef] [PubMed]
5.    Fiani, N.; Verstraete, F.J.; Arzi, B. Reconstruction of congenital nose, cleft primary palate, and lip disorders.
      Vet. Clin. North Am. Small Anim. Pract. 2016, 46, 663–675. [CrossRef] [PubMed]
6.    Tolwani, R.; Hagan, C.; Runstadler, J.; Lyons, H.; Green, S.; Bouley, D.; Rodriguez, L.; Schendel, S.;
      Moseley, M.; Daunt, D.; et al. Magnetic resonance imaging and surgical repair of cleft palate in a
      four-week-old canine (Canis familiaris): An animal model for cleft palate repair. Contemp. Top. Lab. Anim. Sci.
      2004, 43, 17–21. [PubMed]
7.    Peralta, S.; Fiani, N.; Kan-Rohrer, K.H.; Verstaete, F.J. Morphological evaluation of clefts of the lip, palate,
      or both in dog. Am. J. Vet. Res. 2017, 78, 926–933. [CrossRef] [PubMed]
Vet. Sci. 2018, 5, 61                                                                                           7 of 7

8.    Lee, Y.H.; Liao, Y.F. Hard palate-repair technique and facial growth in patients with cleft lip and palate:
      A systematic review. Br. J. Oral Maxillofac. Surg. 2013, 51, 851–857. [CrossRef] [PubMed]
9.    Osuji, O. Preparation of feeding obturators for infants with cleft lip and palate. J. Clin. Pediatr. Dent. 1995,
      19, 211–214. [PubMed]
10.   Agarwal, A.V.; Shafi, S. A feeding appliance for a newborn baby with cleft lip and palate. Natl. J.
      Maxillofac. Surg. 2010, 1, 91–93. [PubMed]
11.   Smith, M.M.; Rockhill, A.D. Prosthodontic appliance for repair of an oronasal fistula in a cat. J. Am. Vet.
      Med. Assoc. 1996, 9, 1410–1412.
12.   Hale, F.A.; Sylvestre, A.M.; Miller, C. The use of a prosthetic appliance to manage a large palatal defect in a
      dog. J. Vet. Dent. 1997, 14, 61–64. [PubMed]
13.   Yamamoto, S. The effects of food consistency on maxillary growth in rats. Eur. J. Orthod. 1996, 18, 601–615.
      [CrossRef] [PubMed]
14.   Herfert, O. Fundamental investigations into problems related to cleft palate surgery. Br. J. Plast. Surg. 1958,
      11, 97–105. [CrossRef]
15.   Bardach, J.; Kelly, K.M.; Salyer, K.E. A comparative-study of facial growth of facial growth following
      lip and palate repair performed in sequence and simultaneously-an experimental-study in beagles.
      Plast. Reconstr. Surg. 1993, 91, 1008–1016. [CrossRef] [PubMed]
16.   Ophof, R.; Jaap, C.; Von Den Hoff, J.W.; Kuijpers-Jagtman, A. Histologic evaluation of skin-derived and
      collagen-based substrates implanted in palatal wound. Wound Repair Regen. 2004, 12, 528–538. [CrossRef]
      [PubMed]
17.   Bokemeyer, J.; Fehr, M.; Meyer-Lindenberg, A. Cleft palate repair using a collagen matrix (VetBiosist® ).
      Tierarztl. Prax. Ausg. K Kleintiere Heimtiere 2009, 37, 173–178.
18.   Peralta, S.; Nemec, A.; Fiani, N.; Verstraete, F.J.M. Staged double-layer closure of palatal defects in 6 dogs.
      Vet. Surg. 2015, 44, 423–431. [CrossRef] [PubMed]
19.   Nemec, A.; Daniaux, L.; Johnson, E.; Peralta, S.; Verstraete, F.J.M. Craniomaxillofacial abnormalities in dogs
      with congenital palatal defects: computed tomographic findings. Vet. Surg. 2015, 44, 417–422. [CrossRef]
      [PubMed]
20.   Kemp, C.; Thiele, H.; Dankof, A.; Schmidt, G.; Lauster, C.; Fernahl, G.; Lauster, R. Cleft lip and/or palate
      with monogenic autosomal recessive transmission in Pyrenees shepherd dogs. Cleft Palate Craniofac. J. 2009,
      46, 81–88. [CrossRef] [PubMed]
21.   Meng, L.; Bian, Z.; Torensma, R.; von den Hoff, J.W. Biological mechanisms in palatogenesis and cleft palate.
      J. Dent. Res. 2009, 88, 22–33. [CrossRef] [PubMed]
22.   Moura, E.; Cirio, S.M.; Pimpao, C.T. Nonsyndromic cleft lip and palate in boxer dogs: Evidence of monogenic
      autosomal recessive inheritance. Cleft Palate Craniofac. J. 2012, 49, 759–760. [CrossRef] [PubMed]

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